ICD-10
Presented by:
Karen Kvarfordt, RHIA, CCS-P, CCDS
AHIMA Approved ICD-10-CM/PCS Trainer
President, DiagnosisPlus, Inc.
2015
1

It will change the way in which we document patient care in our medical records both in the hospital and in our physician practices.
Tell the patient story better!
2




WHO (World Health Organization) owns & publishes ‘ICD’ (International Classification of
Diseases).
WHO endorsed ICD-10 in 1990; members began using ICD-10 or modifications in 1994.
United States is the only industrialized country not using ICD-10 for our coding & reporting of diseases, illnesses, and injuries. Why?
What makes us so different?
3









United Kingdom (1995)
Denmark, Finland, Iceland, Norway, Sweden
(1994 – 1997)
France (1997)
Australia (1998)
Belgium (1999)
Germany (2000)
Canada (2001) ( 30,000 diagnosis codes)
United States (2015)

( Reimbursement + Case Mix )
4






Currently the U.S. health care industry uses ICD-9-CM codes for identifying and reporting diagnoses and procedures.
ICD-10 will replace the existing ICD-9 code sets (diagnosis
& procedure) effective October 1, 2015 .
ICD-10-CM = Diagnosis codes
ICD-10-PCS = Inpatient hospital procedure codes only
No impact on CPT and/or HCPCS codes!

CPT and HCPCS codes will continue to be used for physician and outpatient services including physician hospital visits (Observation & Inpatient) = E&M
5


ICD-10-CM ( Diagnoses )

Will be used by all hospitals, providers, clinics, lab, radiology, psych, rehab, nursing homes, etc.

ICD-10-PCS ( Procedures )

Will be used only for hospital claims for inpatient hospital procedures

CPT/HCPCS – No change!

Procedures for Hospital Outpatients, Physician
Visits, Lab and Radiology Outpatients, etc.
6


What is the benefit to the provider?

Greater specificity in identifying health conditions.

The greater level of detail in the new code sets will include laterality, severity and complexity of disease conditions, which will enable more precise identification and tracking of specific conditions.

Terminology and disease classification are now consistent with new technology and current clinical practice.
7


Share higher-quality data with other health care providers.

ICD-10 increases the amount of “specific” information in every diagnosis code and makes this more valuable to other providers.

For example, ICD-9 has a code for laceration of a finger.

ICD-10 lets you know if that laceration was of the index, little, middle, ring finger or thumb and if it was left, right, or bilateral.
8


Reimbursements will better align with activity & cost.

Payers will reimburse severe & complex cases better and simple cases at lower rates.

How? By the diagnosis codes!
9


Imagine you had a patient who was noncompliant with their medical therapy.

In ICD-9, the only code we have available is V15.81 (personal history of noncompliance with medical treatment).

Is the patient noncompliant because of their own personal reason? Or something else?
10






Z9111 (Patient’s noncompliance with dietary regimen)
Z91120 (Patient's intentional underdosing of medication regimen due to financial hardship)
Z91128 (Patient’s intentional underdosing of medication regimen for other reason)
Z91130 (Patient’s unintentional underdosing of medication regimen due to age-related debility)
Z91138 (Patient’s unintentional underdosing of medication regimen for other reason)
Shows whether or not the patient’s noncompliance was intentional, but also identifies if the patient needs some form of assistance from social services, etc.
11

12




Allows for greater “ specificity & detail ” which is currently lacking in ICD-9-CM.
Moving from 14,025 ► 69,823 diagnosis codes!

25,000 (36%) of all ICD-10-CM diagnosis codes will now distinguish ‘right’ vs. ‘left’.

Must be documented in the medical record for code capture.
Expanded # of characters of the ICD-10-CM diagnosis codes will provide greater specificity to identify: Etiology, Anatomical site, & Severity
13




Main difference between ICD-9-CM and ICD-
10-CM codes, outside of structural changes, is the “SPECIFICITY” of the code.
ICD-10-CM diagnosis codes will range anywhere from 3 to 7 characters which will allow us to capture this greater detail.
But it must be documented in the record!
14







Stage or grade of disease
Specific anatomical location
Acute vs. chronic
Severity: mild, moderate, severe
Episode of care: initial vs. subsequent vs. sequela

Injuries, Fractures, & Poisonings
Laterality: right, left, or bilateral
15

ICD-9-CM
◦
◦
◦
◦
◦
◦
3 - 5 digits or characters
1st character is numeric or alpha (E or V codes)
2 nd – 5 th characters are numeric
Decimal placed after the first 3 characters
17 Chapters and “V” & “E” codes are ‘ supplemental ’
14,025 diagnosis codes
ICD-10-CM
◦
◦
◦
◦
◦
◦
3 - 7 digits or characters
1 st character is alpha (all letters used except “U”)
2 nd – 7 th characters can be alpha and/or numeric
Decimal placed after the first 3 characters (the same!)
21 Chapters and “V” & “E” codes are ‘ not ’ supplemental
69,823 diagnosis codes
16




ICD-9-CM (irregular astigmatism) (367.22)

Only 1 code currently in ICD-9-CM
ICD-10-CM (irregular astigmatism)

Will have four choices:

H52.211 (irregular astigmatism, right eye)

H52.212 (irregular astigmatism, left eye)

H52.213 (irregular astigmatism, bilateral)

H52.219 (irregular astigmatism, unspecified eye)
Physicians are likely documenting “laterality” now, but coders aren’t looking for it.





LATERALITY


For bilateral sites, the final character of the codes in
ICD-10-CM indicate laterality.
Right side is always character 1 ( RT )
Left side is always character 2 ( LT )

Bilateral code is always character 3 ( RT & LT )
But be careful! Not all codes will have a ‘bilateral’ distinction, i.e., carpal tunnel, etc.
“Unspecified” side code is also provided should the side not be documented in the medical record.
Did we just lose our specificity?
18











Joint pain
Joint effusion
Injuries
Fractures
Dislocations
Arthritis
Cerebral infarction
Extremity atherosclerosis
Pressure ulcers


Seventh (7 th ) character identifies the patient encounter type, with “ A ” for the initial encounter, “ D ” for the subsequent encounter and “ S ” for sequela encounter.

Initial = Patient is receiving ‘active’ treatment

First time being seen for the injury, i.e., ER visit, surgery, evaluation by new physician

Subsequent = Follow-up care

Sequela = Complication of a previous injury
20








I10 Essential (primary) hypertension
S01.02
x A Laceration with foreign body of scalp, initial encounter
S01.02
x D Laceration with foreign body of scalp, subsequent encounter
S02.2
xx A Fracture of nasal bones, initial encounter for closed fracture
H65.0
1 Acute serous otitis media, right ear
H65.0
2 Acute serous otitis media, left ear
H65.0
3 Acute serous otitis media, bilateral
21

22

1
Section
2 3
Root
Operation
4 5
Approach
6 7
Qualifier
Body Body
System Part
Device
23

Endoscopic Esophageal Excision via Natural or Artificial Opening
ICD-9-CM: 45.16 Esophagogastroduodenoscopy (EGD) with Closed Biopsy
0
Section
(Medical/Surgical)
D
Body System
(Gastrointestinal)
B
Root
Operation
(Excision)
5
Body Part
(Esophagus)
8
Approach
(Via natural or artificial opening endoscopic)
Z
Device
(No Device)
X
Qualifier
(Diagnostic)
24

1
Section
(Obstetrics)
Extraction of Products of Conception, Low Cervical,
Open Approach
ICD-9-CM: 74.1 (Low Cervical Cesarean Section)
0
Body System
(Pregnancy)
D
Root Operation
(Extraction)
0
Body Part
(Products of
Conception)
0
Approach
(Open)
Z
Device
(No
Device)
1
Qualifie r
(Low
Cervical)
25

26



Under ICD-10-CM diagnosis codes will be based on the stage of pregnancy:

First trimester

Second trimester

Third trimester
Trimesters are counted from the first day of the last menstrual period, and defined as:


First trimester: Fewer than 14 weeks
Second trimester: Fourteen weeks

Third trimester: Twenty-eight weeks
27



ICD-10-CM contains a separate category for nicotine dependence with subcategories to identify the specific tobacco product and nicotine-induced disorder(s). For example:


Cigarettes
Chewing tobacco

Cigar, etc.
ICD-9 has only one diagnosis code (305.1) for tobacco use disorder or tobacco dependence.
28




New diagnosis code in the ICD-10 world!
Identifies situations in which a patient has taken less of a medication than prescribed by the physician and captures those reason(s).
Must be documented in the record!

Financial

Non-compliance*
29



Burn codes identify:

Thermal burns, except for sunburns, that come from a heat source

Burns resulting from electricity and/or radiation
Addition of the term “ corrosion ” is new in
ICD-10-CM:

Corrosions are burns due to chemicals
30

31

5.
6.
7.
8.
1.
2.
3.
4.
9.
10.
Laterality (left vs. right)
Stage of Care (initial or follow-up)
Specific Diagnosis (acute vs. chronic)
Specific Anatomy (specific bone in the hand)
Associated and/or Related Conditions
Cause of Injury (hit by baseball, fall)
Documentation of Additional Symptoms or Conditions
Dominant vs. Non-Dominant Side
Tobacco Exposure or Use
Gustilo-Anderson Scale
32

33



ICD-10-CM will include 2 diagnosis codes but does not include the abbreviation “GERD”

K21.0 (Gastro-esophageal reflux disease with esophagitis)

K21.9 (Gastro-esophageal reflux disease without esophagitis)
Barrett’s now broken down:


With or without ulcer
With or without dysplasia

Staging of dysplasia

Low grade

High grade 34



Documentation needs to include the specific location:

Gastric


Duodenal
Peptic

Gastrojejunal
Further specificity needs to identify:

Acute or chronic




With hemorrhage
With perforation
With hemorrhage and perforation
Without mention of hemorrhage or perforation
35






Document the Severity (3 levels):
1.
Mild (more than two times per week)
2.
3.
Moderate ( daily and may restrict physical activity)
Severe (throughout the day with frequent severe attacks limiting the ability to breathe)
Clarify whether acute, chronic, intrinsic or extrinsic
Specify exercise-induced or other forms
Specify when chronic state asthmatic bronchitis exists and when acute exacerbation occurs
Document tobacco exposure or history of
36


Documentation in ICD-10-CM needs to identify whether the CHF is acute or chronic and the specific ‘type’ of heart failure:


Combined systolic & diastolic
Diastolic


Systolic
Left ventricular
37


Need to include specificity such as:

Acute or subacute

Further specify with bronchiectasis, COPD, etc.

Allergic


Asthmatic
Chronic


Obstructive
Viral
38



ICD-9 features 59 codes for diabetes, while
ICD-10 offers more than 259 and adds a provision of “poorly controlled” to categories of controlled or not controlled.
Diabetes mellitus codes expanded to include the classification of the diabetes AND the manifestation.

Needs to be clearly documented in the record!
39





Identify Type 1, Type 2, due to other secondary cause, i.e., gestational, etc.
In Type 2 or secondary cause, identify when using insulin long-term.
Identify all body systems affected by the diabetes, i.e., neuropathy and its manifestation, retinopathy and proliferative or nonproliferative, nephropathy and stage of CKD, vasculopathy, etc.
Identify all manifestations, i.e., ulcer, coma, gangrene, osteomyelitis, etc.
40


Medical record documentation must include the specific location of the chest pain:

Anterior wall


Atypical
Intercostal


Musculoskeletal
Non-cardiac

Precordial
41


Documentation will need to include the following to accurately code a fracture in ICD-10-CM:

Displaced or non-displaced

Open or closed

Laterality (left vs. right vs. bilateral)

Specific bone and location of the bone

Distal, proximal, mid-shaft, etc.

Type of Encounter

Initial, subsequent, sequela
42


Subsequent encounter for open and closed fractures:

Used for encounters after active fracture treatment has been completed and the patient is receiving routine care during the healing or recovery period.

Closed Fracture 7 th Character Extensions:

D ► Routine healing or aftercare

G ► Delayed healing

K ► Nonunion

P ► Malunion
43


Gustilo-Anderson classification identifies the ‘ severity of soft tissue damage ’ in open fractures – may be new to coders and physicians:

Type I : Wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (low energy injury)


Type II : Wound is longer than 1 cm, not contaminated, and w/o major soft tissue damage or defect (low energy injury)
Type III : Wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves highenergy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.
44






Specify location, i.e., inguinal, femoral, umbilical, ventral, diaphragmatic; all other abdominal hernias default to “other”, etc.
Specify unilateral (which side) or bilateral
Specify with obstruction when present
Specify with gangrene when present
Specify when recurrent hernia (defaults to primary)
45



Malignant Neoplasm Breast

54 choices for male/female breast
Documentation must include:


Laterality
Location (site)


Use of an additional code to identify estrogen receptor status
Example: C50.422 (Malignant neoplasm of upper-outer quadrant of the left male breast)
46




Malignant Neoplasm Lung/Bronchus
63 choices available in ICD-10-CM
Documentation must include:

Specific site/location

Hilus, lingula, main bronchus, lower lobe, middle lobe, upper lobe, etc.

Example: C34.2 (malignant neoplasm of middle lobe, bronchus or lung)

Laterality




ICD-10-CM diagnosis codes will impact every physician practice large or small!
Look at all areas that will impact your practice and identify each one that will be affected:

Practice Management System

Electronic Medical Record (EMR)

Paper record

Superbill/encounter form – does it have diagnosis codes on it?

Lab requisitions/orders
48



Although the coding book is “huge”, many physician practices use only a small set or # of diagnosis codes.
Start developing crosswalks between ICD-9-
CM & ICD-10-CM codes you use most frequently in the office.
49

50

Contact Info:
Karen Kvarfordt, RHIA, CCS-P, CCDS
AHIMA Approved ICD-10-CM/PCS Trainer
President, DiagnosisPlus, Inc.
PO Box 486
Pocatello, ID 83204
(208) 221-5486 diagnosisplus1@live.com
51